A nurse is providing teaching to a female client who has herpes simplex virus type 2. Which of the following client statements indicates an understanding of the teaching?

Choice A rationale:
Placing the client on droplet precautions is appropriate for bacterial meningitis, as it is spread through respiratory droplets. This measure helps prevent the spread of infection to others.
Choice B rationale:
The nurse should clarify the prescription to perform a cranial nerve assessment every 2 hours. While cranial nerve assessment is crucial in monitoring neurological status, performing it every 2 hours is excessive and not supported by evidence-based practice. Frequent assessments can be uncomfortable for the client and may not provide additional meaningful information within such a short interval.
Choice C rationale:
Assisting the client out of bed three times per day is essential for promoting mobility and preventing complications such as pressure ulcers and muscle weakness. This prescription is appropriate and does not require clarification.
Choice D rationale:
Assessing the client's weight daily is essential in monitoring fluid balance and nutritional status. There is no need to clarify this prescription, as it is a standard practice in caring for clients with bacterial meningitis.

Choice A rationale:

A defined area of cool, boggy skin is not indicative of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, usually appearing as a shallow open ulcer with a red-pink wound bed, without slough or bruising.

Choice B rationale:

A shallow crater involving the epidermis is characteristic of a stage 2 pressure injury. It presents as a partial-thickness skin loss with the loss of the epidermis, and the wound may be superficial and appear as an abrasion, blister, or shallow ulcer.

Choice C rationale:

The reddened area that does not blanch is more indicative of an early-stage pressure injury (Stage 1). In Stage 1, the skin remains intact, but there is non-blanch-able erythema indicating damage to the skin and underlying tissue.

Choice D rationale:

Undermining or tunneling of the skin is not specific to stage 2 pressure injuries. These features may be observed in more advanced stages of pressure injuries, such as stages 3 and 4, where there is full-thickness skin loss with damage to the subcutaneous tissue and underlying structures.